ULREDC Rental Application

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Page 1

This application is in two parts.
The first is the rental application. The 2nd is an Emergency
Contact Form. Both are required for your application to be complete.
Once you complete the rental application and hit “Submit”, you will be
directed to the Emergency Contact Form. Be sure to complete both!

All applicants over 18 years of age are subject to a $15.00 credit check fee and criminal/background records check. Fees may be collected at time of applicant interview. Failure to pay fees may result in denial of housing opportunity. Applicants will need to provide copies of required documents, social security cards and birth certificates for all household members before occupancy. REV 6-17

Page 2

Date

Applicant Name

Gender

Current Address

City

State

Zip

Home Phone

Cell Phone

Email Address

Work Phone

May We Contact You At Work?

Birth Date

***Please note*** - Your social security number will be required to complete your application.

Is the Head of Household, co-head/spouse 62 or older?

Are you enrolled in the U.S. Military or are you a veteran of the U.S. Military?

Are you a victim of a recent presidentially declared disaster?

Are you currently receiving housing assistance from HUD or a PHA?

Page 3

Have you ever been asked to sign a repayment agreement to return money to HUD?

Have you ever been convicted of a crime?

If yes, indicated if the conviction(s) was a felony, misdemeanor or check both boxes if you have been convicted of both.

Are you or is any member of the household required to register with any state lifetime sex offender or other sex offender registry?

Have you ever been evicted from a federally funded housing program for a lease violation including drug use or failure to report a crime?

If yes, when?

Please provide a complete list of states where you have lived. This disclosure is mandatory under HUD rules and criminal screening will be reviewed in each state listed and via national criminal screening/sex offender databases. Failure to provide a complete and accurate list will result in the rejection of the application.

Please place a check next to each state where you have lived. Please include Washington, D.C. if you have lived in Washington, D.C.

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Washington D.C.

Page 4

Present Landlord Information

Present Landlord

Landlord Address

City

State

Zip

Contact Name (if known)

Phone Number

How long did you live at this address?

Reason for Leaving

Were you ever asked to allow or participate in extermination of pests other than regularly scheduled pest control? (Includes roaches, bed bugs, rodents, etc.)

Did you owe the previous landlord any money when you left or do you currently have any outstanding balances owed to this landlord?

Are you currently receiving housing assistance from HUD?

Have you given this landlord notice that you will be moving?

Have you been evicted or is this landlord attempting to evict you or another person living with you?

Page 5

Previous Landlord(s) - If you have not had a previous landlord, type N/A in required fields.

Previous Landlord Name

Address

City

State

Zip

Contact Name (If Known)

Phone Number

How long did you live at this address?

Reason for Leaving

Were you ever asked to allow or participate in extermination of pests other than regularly scheduled pest control? (Includes roaches, bed bugs, rodents, etc.)

Did you owe the previous landlord any money when you left or do you currently have any outstanding balances owed to this landlord?

Have you ever been asked to sign a repayment agreement to return money to HUD?

UTILITY PROVIDERS: You may not live in the unit unless you can establish utilities in the unit.

Do you have any current outstanding balances owed to any utility provider?

Will you be able to establish utilities in your unit?

Electric............

Gas............

Water............

Page 6

Other Members

Will anyone else live in the unit with you? (If yes, please note that all adults must complete their own application.)

Household member's full name

Relationship to Head of Household

Please provide a complete list of states this person has lived. This disclosure is mandatory under HUD rules and criminal screening will be reviewed in each state listed. Failure to provide a complete and accurate list will result in the rejection of the application.

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Washington D.C.

Page 7

Unit Size:

The owner/agent will take your unit preferences/requirements in to consideration. The owner/agents occupancy standards indicate a minimum of one person per bedroom and maximum of two people per bedroom.

If you request a unit size different from these standards, the owner/agent is required to verify the need for a larger or smaller unit in accordance with HUD Handbook 4350.3 Revision 1. Please indicate unit size preferences below.

If you require special unit features, the owner/agent may verify the need for those features in accordance with HUD Handbook 4350.3 Revision 1. Please indicate any necessary special features below.

Pets & Assistance/Companion Animals: Please review the property pet/assistance animal rules. The presence of any animal must be approved before the animal is allowed to be kept in the unit.

Do you plan to house an animal in the unit?

Please enter animal information here

Animal Type (Cat, Turtle, etc.)

Breed (If Applicable)

Height (Measured at withers if applicable)

Weight

Is this animal required to live in the unit to alleviate the symptom(s) of a disability for a household member (e.g. companion animal or service animal)?

Page 8

INCOME AND ASSET INFORMATION: In order to determine eligibility and to ensure that your family receives the correct assistance, please provide the following information.

Are you employed?

Please provide the name and address of your present employer(s) below.

Employer Name

Address

City

State

Zip

Phone

How much employment income do you expect to receive in the next 12 months?

Page 9

Income Sources

Do you expect to receive other income in the next 12 months from other sources?

Click here to name this section

Monthly Social Security

Check

Direct Deposit

Prepaid Debit Card

None

Amount

Monthly Retirement Benefits?

Check

Direct Deposit

Prepaid Debit Card

None

Amount

Monthly VA Benefits?

Check

Direct Deposit

Prepaid Debit Card

None

Amount

Monthly Unemployment Benefits?

Check

Direct Deposit

Prepaid Debit Card

None

Amount

Monthly Child Support

Check

Direct Deposit

Prepaid Debit Card

None

Amount

Monthly Alimony

Check

Direct Deposit

Prepaid Debit Card

None

Amount

Monthly Public Assistance

Check

Direct Deposit

Prepaid Debit Card

None

Amount

Income from a pension or annuity or other asset?

Regular contributions from organizations or from individuals not living in the unit?

Periodic Payments from Long-Term Care Insurance, Disability or Death Benefits?

Contributions from family for rent, child care or other bills.

Lump sum amounts from delay of payments for SSI or VA Disability

Do you receive financial aid for education assistance?

Annual amount of education assistance.

Any other income?

Are you a full time student?

Is anyone else in your household a full time student

Page 10

Assets

Have you sold or
given away real property or other assets valued at $1000.00 or more (including
cash donations) in the past two years?

Have you given any money to charities in the past two years?

Are any benefits deposited in to a Direct Express Debit Card account?

Do you have a checking account? (If you answered yes, you will be required to provide the most recent six months’ bank statements so that we may estimate the value of the asset in accordance with HUD requirements. Please save your bank statements.)

Do you have a savings account?

Current Balance - Please write in 0 if the account balance is zero.

Do you have cash that is not deposited in an account?

Current Value - Please write in 0 if the account balance is zero.

Do you have a 401K or other employment savings account?

Current Value - Please write in 0 if the account balance is zero.

Do you own an IRA or other retirement account?

Current Value - Please write in 0 if the account balance is zero.

Do any of your retirement accounts have a Required Minimum Distribution?

Amount

Do you own a home or other property?

Current Value - Please write in 0 if the asset value is zero.

Do you have business income?

Current Value of Business - Please write in 0 if the asset value is zero.

Do you own stocks/bonds/certificates of deposit (CD)?

Current Value - Please write in 0 if the asset value is zero.

Do you own a life insurance policy?

Current Value - Please write in 0 if the asset value is zero.

Do you own an annuity?

Current Value - Please write in 0 if the asset value is zero.

Is there a trust fund in your name or have you established a trust fund for someone else?

Current Value - Please write in 0 if the asset value is zero.

Do you have a safety deposit box?

Are assets stored in the safety deposit box such as US Savings Bonds, cash, stocks, etc.

Do you have access to any other assets, property, insurance policies, businesses, etc.?

If yes, please provide a description of the asset(s) and the current asset value below:

Page 11 - Deductions

Deductions

This section only needs to be completed if you are applying for HUD 811 or HUD 202 Housing. If you are seeing this message just skip and go to the next page.

DEDUCTIONS: Household income can be reduced based on the amount of qualified monthly expenses. Please let us know if you have out-of-pocket expenses for the following:

Households in which the head-of-household, co-head of household or spouse are disabled or at least 62 years old qualify for deductions based on out-of-pocket medical expenses. Please let us know if you or any members of your household have out-of-pocket expenses for the following:

Health
Insurance - 1– annual premium

Health
Insurance - 1– annual deductible

Health
Insurance - 2– annual premium

Health
Insurance - 2– annual deductible

Dr. visit/medical treatments - annual out-of-pocket expense

Prescription Drugs - annual out-of-pocket expense

Do you have an HMO, a medical plan, or health insurance policy, which pays all or part of the cost of your medications?

If yes, please give the name of the HMO, plan, or insurance company.

What amount (or percentage) of the cost must YOU pay?

If you must pay for the medicines yourself, are you later reimbursed all or part of the cost?

Are there any other medical expenses, which you pay, that we should consider when calculating your rent?

Other? (List Expenses and Amounts)

Page 12

Please provide the information below for the Head of Household and any other person to live in the unit. Head of Household and Co-Head of Household MUST fill out this form.

Household Information

First Name

Last Name

Sex/Gender

Date of Birth

edit hint text

Relationship to Head of Household

Head of Household (self)Co-HeadSpouseFoster Child/AdultDependentNon-MemberOther Adult

Ethnicity (select one)

Hispanic or LatinoNot Hispanic or Latino

Race (select all that apply)

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite

Page 13

PENALTIES FOR MISUSING THIS FORM

Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department of the United States Government, HUD, the PHA and any owner (or any employee of HUD, the PHA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited above. Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the PHA or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7) and (8). Violation of these provisions are cited as violations of 42 U.S.C. 408 (a) (6), (7) and (8).

APPLICANT CERTIFICATION

By signing this document, I certify that if selected to receive the unit I/we occupy will by my/our only residence. I/we understand that the above information is being collected to determine my/our eligibility. I/we authorize the owner/manager/PHA to verify all information provided on this application and to contact previous or current landlords or other sources of credit and verification information which may be released to appropriate Federal, State, or local agencies. I/we certify that the statements made in the application are true and complete. I/we understand that providing false statements or information is punishable under Federal Law.

Applicant Name (please print in lieu of signature)

Date

ULREDC does not discriminate on the basis of disability status in the admission or access to, or treatment or employment in, its federally assisted programs and activities.

The person named below has been designated to coordinate compliance with the nondiscrimination requirements contained in the Department of Housing and Urban Development’s regulations implementing

Section 504 (24 CFR, part 8 dated June 2, 1988).

Name Abi Phillips

Address312 State St

City Rochester, NY 14608

Telephone 585-454-5710 x 2007

See HUD Handbook 4350.3 Revision 1, Paragraph 2-29-c-3 & 4 for information about the requirements to include this information.

This application is in two parts.
The first is the rental application. The 2nd is an Emergency
Contact Form. Both are required for your application to be complete.
Once you complete the rental application and hit “Submit”, you will be
directed to the Emergency Contact Form. Be sure to complete both!